GGIL North Carolina Cohort Reflections

The North Carolina Cohort is an excellent example of the great work the Gillings School engages in across North Carolina. Drawing by John Roman

Course Overview  |  Student Reflections

Course Overview

The Gillings Global Implementation Lab (GGIL) is an exciting new three credit hour, graduate-level, interdisciplinary, field-based course in which students apply knowledge and experience to systematically design and implement solutions to complex public health problems in North Carolina and around the world.  Teams of 5-8 students build problem solving and implementation capacity working on a public health project in partnership with governmental, non-governmental or private sector organizations.  Students acquire valuable applied experience and develop generalizable insights and sound implementation practices. This team will be working with Wake County Human Services. The team will be blogging during their time with Wake County to help give you an inside look on the work this new and exciting class is doing in North Carolina.


Student Reflections

Wake County can count on UNC (NC Student Team)

The United States continues to struggle with high rates of sexually transmitted infections (STIs). The Centers for Disease Control and Prevention estimates that there are nearly 20 million new infections each year in the United States. Screening and prompt treatment are essential tools in the effort to minimize long-term health consequences of STIs and prevent further transmission. There is significant demand for these services, a large portion of which has fallen local health departments where care is provided at low or no cost.

Wake County Human Services operates an STI clinic, also known as Clinic A that provides testing, diagnosis, and treatment Monday through Friday. There are over 12,000 visits to this clinic yearly, and, although there are some appointments available, the vast majority of patients are seen as walk-ins. Clientele are largely low-income African-Americans and Latinos, and services are provided to uninsured patients at no cost. Although Clinic A, like so many other public institutions, is under-resourced, its staff work hard to provide the best possible patient care.

The challenge posed to our domestic student team in SPHG690 is patient turn away at Clinic A. As most patients are seen on a walk-in basis, it is difficult to predict the number who will arrive on a given day. Consequently, more patients may arrive than can be accommodated, and some are turned away without being seen by a provider. It is important to note that Clinic A is the only free clinic in Wake County: If low-income patients are turned away, there is nowhere else for them to go. Furthermore, this particular clinic has a high rate of positives, so there is potential for the spread of disease when patients are turned away.

We will be attempting to reduce turn away solely by altering work flow—that is, without increasing clinician hours or changing the physical layout of the clinic. This concept of streamlining processes, as opposed to requesting more resources, or requiring already hard-working staff to work harder, is at the heart of the methodology that we will learn in SPHG690.

Monday, March 10, 2014- Off to Raleigh we go! (Monday Team)

The sun rises over I-40. Photo by Evan Fernandez

The sun rises over I-40. Photo by Brianne Kallam

On the first day of spring break, we set off for Raleigh at 6:45 a.m. This week we are implementing changes with the goal of reducing wait time and patient turnaway at the Wake County Human Services STI clinic.

Our two early-morning implementation tasks were to place a sign at the queue instructing patients to have their IDs ready, and to bring the first clients who arrived directly into intake. These were completed successfully.

Improved staff communication tool. Photo by Eva Fernandez

Improved staff communication tool. Photo by Brianne Kallam

We have also dedicated time to the preparation of materials for Tuesday’s implementation tasks. We formatted and assembled new registration packets for patient use in the waiting room. The clinic currently has 11 clipboards for these packets, but, after further discussion, we arrived at the conclusion that the ideal number of clipboards would be 25. Our plan was to implement this tomorrow; however, as the resources that were needed to implement this change are not available, we must alter our plan and await the arrival of our additional clipboards on Tuesday or Wednesday.

Our second major project, in addition to shifting the time and location of patient paperwork, is facilitation of communication among staff members who provide different services. To that end, we created a staff communication board, as well as a reference sheet of daily walk-in numbers.

Tuesday, March 11, 2014- Operation Clipboard (Tuesday Team)

So many clipboards! Photo by Brianne Kallam

So many clipboards! Photo by Brianne Kallam

The commute to Raleigh was rough this morning, lots and lots of traffic. The traffic report said it was too bright to drive but maybe people wanted some time in the sunshine before work.

Ashley does not have enough clipboards.  Photo by Brianne Kallam

Ashley does not have enough clipboards. Photo by Brianne Kallam

Upon our arrival at the clinic, we met with some of the administrative staff and they were very excited about the communications board our team designed. We are hopeful that this board will improve the daily communication at the front desk. The staff brought up some important concerns about patient confidentiality and together we came up with creative solutions to protect the privacy of the patients.

The resources we ordered yesterday arrived! It was surprising and exciting that they arrived overnight!! We assembled the clipboards for patients to fill out in the waiting room and created the shred boxes to ensure proper disposal of patient information.  The clinic director and the quality improvement specialist helped us to refine the work plan for the use of the clipboards.

We are looking forward to our meeting tomorrow with the staff to get their feedback and discuss the more complex changes ahead.

Wednesday, March 12, 2014- When the Patients Are Away, We Shall Role-Play (Wednesday Team)

Today the clinic was closed to patients, as the providers were away for a training session. This allowed us training (and bonding!) time with the support staff without the daily organized chaos of patients and clinic flow.

Operation Clipboard: Behind the scenes with Jen. Photo by E. Fernandez

Operation Clipboard: Behind the scenes with Jen. Photo by E. Fernandez

The focus group began with the staff sharing their experiences implementing the Monday and Tuesday changes. We discussed the challenges that staffing changes have caused in our expedited registration process, as the clinic is currently down one intake staff member. However, the staff was confident that they could maintain the new flow.

Next, we talked through the new work plans for our last three, and biggest, changes. We explained Operation Clipboard and, based on the staff input we received during that conversation, made some additional alternations to the clipboard contents. We went over the new communications board and the multiple ways it could aid visual communication, as opposed to the verbal communication that has, until now, required the staff members to walk to and fro. The staff also explored the new appointment schemes in the GE practice manager, and we talked through scenarios where they would offer appointments to patients rather than turning them away.

Once we had discussed all of the new work plans, we got on our feet and put these plans into motion. The student team (and Brenda, the administrative-supervisor-turned-actress extraordinaire) played the roles of patients as the staff practiced the new processes. This enabled us to work through details and unforeseen complications. Everyone agreed that this was highly useful and surprisingly fun! The staff really delved into their roles. Brenda put the staff through their paces by perfectly embodying a challenging patient:

Role playing with Brenda and Melanie.  Photo by E. Fernandez

Role playing with Brenda and Melanie. Photo by E. Fernandez

Melaine: “Here is your number.”

Brenda: “What’s this?”

Melaine: “That’s your number.”

Brenda: “I am not a number!”

The role-playing prepared the staff well for the complete change package. We also altered the work plans based on the outcomes of the role-playing. We finished the day by updating our agenda for the rest of the week and planning for our post-implementation data collection.

Stay tuned for more exciting news from Clinic A!

Thursday, March 13, 2014- Troubleshoot Thursday (Thursday Team)

Once again, a bright rising sun illuminated our drive to Raleigh. We began our day at the clinic by checking in with staff on the use of the communication board and the clipboards that had been the focus of yesterday’s training. Everything was in place, and staff began to roll out these changes as soon as the doors opened to patients.

One of our team members sat at the registration desk during the morning clinic to observe implementation and answer any questions that staff had about the communication board. Although staff were using the board consistently, we soon discovered that the appointment magnets were not as useful as we had hoped. We had a brief brainstorming session to create a potential solution, and then talked with the supervisor about whether our plan might work. She agreed with our proposal and offered to help us implement these new changes.

Meanwhile, we entered the timing data from our first round of data collection into an Excel spreadsheet, and crafted a plan to conduct a process evaluation. Drawing from our prior knowledge and the readings from the class, we laid out a chart of process objectives, measurement instruments, and data collectors. We look forward to reviewing our plan with the teaching team during our meeting next week.

After a break for a delicious lunch at Raleigh’s best BBQ place, we came back to the clinic to put together even more clipboards and create extra magnets for the communication board. Currently there are papers strewn all over the floor, along with boxes of clipboards and stray pieces of string from tying pens. You can tell we’ve been busy!

Tomorrow we have a meeting scheduled with staff to discuss some of the successes and challenges of today’s implementation. We are interested to hear their feedback and ideas, and, of course, we will share it with all of you, our loyal followers.

Friday, March 14, 2014- To prevent a muddle, you must huddle (Friday Team)

Still Life with Latte and Bagel.  Photo by E. Fernandez

Still Life with Latte and Bagel. Photo by E. Fernandez

We started the day bright and early, again, at a café in Carrboro, where we worked further on our process evaluation plan. The Module 3 reading was useful to us during this task, and we can’t wait to learn more in Module 4.

GGG_sphg_Jen drinks her coffee black, like the no-nonsense New Jerseyan that she is

Jen drinks her coffee black, like the no-nonsense NJ woman that she is. Photo by E. Fernandez

We traveled to Raleigh for a morning “huddle” with the support staff. Our goals were to troubleshoot the implementation, as necessary, and to solicit further feedback on the staff’s experience. We asked the staff whether a tweak was necessary in order to improve the usefulness of the communication board with regard to patients who have appointments, but the staff informed us that the system was already working well.

In fact, the staff were universally delighted with the communication board. Quoth Brenda: “I LOVE that board.” Shonda said that she liked that it was “very visual.” Of all our implemented changes, the board has been the most welcome by far.

We also prepared the staff for the process and outcomes evaluations that we will conduct during the week of March 24th. Jen did a brilliant job of condensing a semester’s worth of studying into a minute-long overview. We explained that some of our data collection methods might be different this time around, but others would already be familiar to them from our pre-implementation phase.

We stayed into the afternoon for final observations. Everything went smoothly. Overall, it seems that the week has been a productive experience for all involved, and we are looking forward to determining whether our changes have had a positive impact.

Monday, May 5, 2014- Results and Looking Ahead (NC Student Team)

As we conclude our project with Wake County, we are thrilled to share our results. First, a refresher: Our readers might recall that we implemented five main changes, targeting three aspects of clinic functioning. For intake and registration, we expedited registration for the first two patients, introduced clipboards for patient information collection, and created a chart of the initial number of walk-in appointments. For appointments and scheduling, we developed a same-day/next-day appointment procedure for patients who could not be seen at a particular clinic. Finally, for staff communication, we created a visual communication board.

Our specific goal for this project was a 50% reduction in patient turn away at Clinic A. According to the NC student team’s definition, we achieved a 74% reduction in patients turned away. According to Wake County’s definition, we achieved a 100% reduction in patients turned away. By either measure, our partnership was a great success! Our statistical tests further showed that our changes had significantly reduced the variability of waiting times, which meant greater equity among patients.

The NC student team presented these results at a meeting with Clinic A staff on the morning of April 29th. We also made several recommendations for the future. First, we suggested that Wake County continue to monitor and fine-tune the five initial changes that were implemented during our collaboration. Second, we suggested that Wake County carry out future improvement cycles to reduce interruptions to clinic flow. Finally, we suggested that Wake County use available technology to reduce steps, particularly in light of their anticipated movement to electronic medical records in August 2014.

This project taught us more than just theory—it taught us important lessons about the real-life application of quality improvement tools. We learned the importance of stakeholder ownership, of flexibility, and of balanced goals and expectations. We hope that Wake County found this project as beneficial as we did, that we have supported them in growing their change culture, and that they will find our tools useful as they work towards continuous improvement. We extend our deepest thanks to all of the Wake County staff who welcomed us into their world and helped to build this rewarding partnership.


 If you have any questions or comments about the course, please contact Anita Farel, Suzanne Hobbs, and Rohit Ramaswamy.